Hindawi Publishing Corporation

International Journal of Dentistry

Volume 2014, Article ID 869067, 5 pages
http://dx.doi.org/10.1155/2014/869067

Clinical Study
Bisphosphonate Related Osteonecrosis of the Jaw:
A Study of 18 Cases Associated with Fungal Infection

V. Aftimos,1 T. Zeinoun,2 R. Bou Tayeh,2 and G. Aftimos1

1
National Institute of Pathology, Faculty of Medicine, Lebanese University, Rafic Hariri Campus, Baabda,
Hadath, Lebanon
2
Department of Oral and Maxillo-Facial Surgery, Faculty of Dentistry, Lebanese University, Rafic Hariri Campus,
P.O. Box 6573/14, Museum, Badaro, Beirut, Lebanon

Correspondence should be addressed to T. Zeinoun; zeinountoni@gmail.com

Received 22 October 2013; Accepted 10 December 2013; Published 18 February 2014

Academic Editor: Samir Nammour

Copyright © 2014 V. Aftimos et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Osteonecrosis of the jaw (ONJ) is a serious complication associated with oral and intravenous bisphosphonate therapy. Its
pathogenesis is not well understood and its management is difficult. Microbiological investigations have detected a variety
of oral pathogens such as Actinomyces, Enterococcus, Candida albicans, Aspergillus, Haemophilus influenzae, alpha-hemolytic
streptococci, Lactobacillus, Enterobacter, and Klebsiella pneumoniae. To better treat it, it is important to understand its causes and
complications. Materials and Methods. Our present study addresses a microscopic observation of curetted jaw necrotic lesions
related to bisphosphonates. Results. A mycotic infestation has been found in all of the 18 cases studied. Discussion. An identification
of the fungal agent and its incrimination in the pathogenesis of bisphosphonates related osteonecrosis of the jaw could change
radically the management of this condition.

1. Introduction
With the increased use of bisphosphonates in the treatment
of osteoporosis and other conditions as multiple myeloma
and [1] bone metastasis and their complications (hypercal-
cemia, pain, pathologic fractures, nephrotoxicity, electrolyte
abnormalities, and spinal cord compression) [1], a side effect
difficult to manage was observed: bisphosphonates related
osteonecrosis of the jaw (BRONJ). BRONJ was described for
the first time in the literature in 2003 [2–5].
“The American Society for Bone and Mineral Research”
defines BRONJ as an area of exposed bone in the maxillofacial
region that does not heal within 8 weeks after its identifica-
tion, by a health care provider, in a patient who is receiving
or has previously been receiving BP and who has not had
radiation therapy to the craniofacial region) as the exposure
of bone in the maxillofacial area for more than 8 weeks.
The patient should have been treated by bisphosphonates
and should not have a history of radiotherapy to the jaw
[6]. Osteonecrosis of the jaw can also be triggered by factors
other than the administering of BPs. It occurs after radiation
therapy of the facial area, trauma (osteotomy of the jaw bone
or during intubation), viral infection (herpes zoster or HIV),
fungal infection with Aspergillus [7], circulatory insufficiency,
local application of chemical agents in dental treatment,
inhaling cocaine, and osteomyelitis [8]. So bisphosphonates
may not be the primary cause. Also in a recent study, Naik
and Russo observed the presence of Actinomyces as an under-
recognized agent in pathogenesis, and timely actinomycosis-
specific treatment may improve outcome [9]. The pathogen-
esis behind this osteonecrosis has not been elucidated yet
but many etiological factors have been incriminated [4]. Also
the lack of science-based guidelines for the management of
patients with this disease makes treatment empiric [3]. In the
cases that we are going to describe, our goal is to demonstrate
a correlation between a fungal infection and BRONJ: is it a
cause or a consequence?
2. Materials and Methods
The population studied was recruited from the entire Leba-
nese territory in a private laboratory of anatomo-pathology
2 International Journal of Dentistry
(a)
(c)
Figure 1: (a) H&E ×40. Overview: necrotic bone medullary spaces filled with hyphae. (b) H&E ×100 necrotic bone, hyphae, and altered
Polymorphs. (c) H&E ×400. Detail: hyphae, and spores in medullary spaces. (d) Groccott ×400. Hyphae and spores.
“National Institute of Pathology.” The cases of osteonecrosis
between January 2008 and June 2013 were reviewed. 31 cases
of osteonecrosis of the jaw were identified during this period.
19 cases were selected, as the patients were known to be
treated by bisphosphonates (I.V). One case was excluded
because the patient was also treated by radiotherapy. Four
cases were reevaluated because of missing data, the evaluation
for a fungal infection was not made initially.
All cases studied are curetting of lesions of osteonecrosis
identified by the treating physician. The specimens are fixed
in formalin at 10%. They are then decalcified by nitric acid at
10% and embedded in paraffin. Slides are cut at 5 microns and
stained by H&E and PAS (Figures 1(a), 1(b), and 1(c)). Some
cases were also stained by Grocott (Figure 1(d)).
The slides were then examined on an optical microscope.
3. Results
18 cases of BRONJ were reported. The population consists of 3
men (17%) and 15 women (83%). The mean age was 58.3 with
a minimum of 39 and maximum of 82. A mycotic infestation
was found in the 18 cases (100%), but the nature of the fungal
agent was not determined. Five out of 18 cases were treated
by zoledronic acid (Zometa 4 mg/100 mL per IV). The rest
of the patients were treated by other I.V bisphosphonates.
One patient was treated for Histiocytosis X, another for colon
cancer, and a third one for breast cancer. Data is missing
concerning the underlying disease for the other 15 patients.
On histologic sections, Figures 1(a), 1(b), and 1(c) ,we
mainly noticed necrotic bone trabeculae and leucocytes,
(b)
(d)
(especially alterated neutrophils) infiltrating medullary spa-
ces. Mycotic spores and hyphae were also noted and were
positive with PAS and Grocott stains (Figure 1(d)).
4. Discussion
Bisphosphonates are pharmacologic compounds character-
ized by high tropism to bone tissue. They affect bone metab-
olism by inhibition of osteoclast recruitment, proliferation,
differentiation and function, resulting in avascular necrosis
[10–12]. They inhibit the osteoclastic activity and thus the
bone remodeling which is an important component of repair
[11]. In vitro, they have a direct toxic effect on the soft tissue of
the oral cavity but we still do not know if their concentration
in vivo is enough to cause the same effect. Bisphosphonates
also diminish neoangiogenesis [13, 14]. Zoledronic acid has
marked antiangiogenic properties that could augment its effi-
cacy in the treatment of malignant bone disease and extend
its potential clinical use to other diseases with an angiogenic
component [15].
In a recent study by Wehrhan et al. [16], mucoperiosteal
tissue samples from BRONJ cases and controls were assessed
for vascularization with CD31 staining and neoangiogenesis
by CD105 evaluation. It was reported that although there was
no difference in vascularization between sample groups, there
were significantly fewer CD105-positive vessels in BRONJ
samples suggesting that neoangiogenesis was suppressed in
BRONJ cases [15, 17, 18]. However, angiogenesis is an essential
factor in healing of wounds. Also, normal vascularization
represents an essential requirement for tissue homeostasis.
International Journal of Dentistry
(a)
(c)
Figure 2: (a) H&E ×100. Necrotic bone trabecula with hyphae and altered polymorphs. (b) PAS ×100 necrotic bone with hyphae. (c) Grocott
×400 hyphae and spores.
Also, local immunity, and regeneration capacity are impor-
tant pre-requirements for repair of all vital tissues of the body,
especially in case of bone tissue that displays a high turn
over rate. CBCT examinations of patients taking bisphos-
phonates might be able to show early bone alterations asso-
ciated with the treatment [19]. New studies are incriminat-
ing a new agent in the pathogenesis of osteonecrosis: the
presence of Actinomyces or Actinomyces-like organisms was
demonstrated almost constantly in histological studies [19–
28]. Other studies have shown the presence of Fusobacterium,
Eikenella, Bacillus, Staphylococcus, and Streptococcus as well
as Actinomyces [21, 22, 29, 30]. If they are part of the biofilm
or they are invasive agents is not yet determined.
The most advanced studies in this field concern Actino-
myces. The presumed sequence is the following: bisphospho-
nates weaken host defenses in the oral cavity and establish a
niche in the bone. An important but not universal condition
to infection is the disruption of the mucosa by dental surgery,
trauma, bad oral hygiene, ill-fitted dentures, and so forth
[23, 25, 27, 31]. Bisphosphonates inhibit the replication cycle
of keratinocytes and thus play a role in the disruption of
the mucosa and the delay in repair [22]. The environment is
at that moment ideal for the development of actinomycosis.
Because viable bone can be found in specimens infected by
Actinomyces; some authors think that Actinomyces infects
the viable bone and does not colonize it secondarily after
necrosis [22, 31]. Others think that because Actinomyces is a
commensal bacteria of the oral cavity, its presence in necrotic
3
(b)
bone must be secondary and is not an etiological factor [27,
30, 32].
In our study, unlike all others, our incriminated agent is a
fungus [32] and not a bacteria—it is stained by PAS and Gro-
cott (Figures 2(a), 2(b), and 2(c)). However, it is important
to stress that cultures taken from an exposed jaw bone may
give misleading results because the isolates may include non-
pathogenic microorganisms that are colonizing the site [33].
We already know that when an Actinomyces is associated,
its specific treatment improves significantly the prognosis of
BRONJ [9] and as we established previously, 100% of our
BRONJ were associated with a fungal infection.
The BRONJ therapy remains an unresolved problem and
there are no evidence-based guidelines. On the basis of the
recent literature it is necessary to consider the treatment
of patients affected by early BRONJ stages with combined
conservative surgical strategies to obtain a greater control of
these lesions for longer periods of time. The previous con-
siderations support the hypothesis that the medical therapy
and alternative noninvasive therapies (LLLT, OZ OTI) can be
effective in jawbone and mucosa defects connected to BRONJ
development [26].
And so, within the same way of thinking, by determining
the nature of this agent as well as the sequence, cause or sec-
ondary infection, a specific antifungal treatment could be
added to the management of BRONJ and it could radically
change its course. A wider analysis of the fungal infection of
BRONJ sites is mandatory to clarify its role.
4 International Journal of Dentistry
Conflict of Interests
The authors declare that there is no conflict of interests
regarding the publication of this paper.
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